Angina Pectoris Caused by the Anomalous Origin of the Right Coronary Artery from the Left Aortic Cusp

Part1: Coronary artery anomalies are reported in 1.3% of patients undergoing coronary angiography1 and may be associated with sudden death, myocardial ischemia, arrhythmia, and syncope. Some anatomic presentations of coronary anomalies are considered to be high-risk;2,3 however, many patients are asymptomatic. Part2: Before the presentation of sudden cardiac death, early detection of potential lethal cases is difficult.4 We report an anomalous origin of the right coronary artery (RCA) from the left coronary cusp with a malignant course, leading to ischemic symptoms for the patient. A 42-year-old woman with a past medical history of diabetes mellitus presented with angina pectoris. She had a history of chest pain of 2 month's duration, which was sometimes precipitated by effort. On admission, her electrocardiogram and cardiac enzyme levels were normal. Her echocardiography was within normal limits, and cardiac catheterization showed that the cannulation of the left main coronary artery displayed was normal. Part3: The course of the left main artery was normal without significant lesion in the left system. Attempts to cannulate the RCA with the right Judkins catheter were unsuccessful. Aortography revealed an anomalous origin of the RCA. Cannulation of the RCA was done successfully with a left Amplatz catheter and demonstrated an anomalous origin of the RCA from the left coronary cusp and mild narrowing of its proximal portion (Figures 1 and 2). Coronary computed tomography angiography was done to determine the RCA course, and it showed a malignant inter-arterial RCA course (Figures 3 and 4). The patient was referred to the cardiac surgery department and underwent surgery. The right internal mammary artery was grafted to the RCA. The patient was symptom-free after surgery and was discharged from hospital with good condition.(